306005516-10-21-2022-22-AS-JHAY-CKEQV5-20221021122945

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005516
Report Date: 10/21/2022
Date Signed: 10/21/2022 12:30:14 PM

Document Has Been Signed on 10/21/2022 12:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	ST. IRENEUS CARE VILLA		FACILITY NUMBER:	306005516
ADMINISTRATOR:	ALIPIO JR, IRENEO D		FACILITY TYPE:	735
ADDRESS:	10030 HOLDER ST		TELEPHONE:	(714) 699-1327
CITY:	BUENA PARK	STATE: CA	ZIP CODE:	90620
CAPACITY: 4		CENSUS: 3	DATE:	10/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Divina Joy Alipio		TIME COMPLETED:	12:35 PM

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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced visit for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Staff called the Administrator (AD) DIvina Alipio via telephone who arrived and was present for the visit. AD Alipio has a current administrators certificate that expires 11/2/23.

At 10:35 AM LPA Haley began the tour of the facility. There were three clients present during the visit. In the living room LPA Haley observed a screening station near the front door with a temperature thermometer, screening log books, hand sanitizer, mask, face shields, and gloves. There is an office set up in in a section of the living room with two file cabinets used to store staff files, supplies for the clients, and a P&I drawer that remains locked. There's a shelf with client files and a first aid kit with all the required elements.

All client bedrooms were clean, well organized, and had all necessary requirements: night stand, chair, lamp and storage space. All client bathrooms were clean and organized. Hot water temperature was measured at 108.2 degrees Fahrenheit in client bathroom #1, 113.5 degrees Fahrenheit in client bathroom #2, 113.9 degrees Fahrenheit in client bathroom #3 112.1 degrees Fahrenheit in client bathroom #4. In client bedroom #2 the closet door has been removed due to his behavior.

The kitchen was clean and organized. All knives and sharp objects were locked in a drawer near the stove. Three of four burners on the stove were operational. LPA Haley advised AD Alipio of the importance of the facility being in good repair at all times. There was a fully charged fire extinguisher mounted near the sink. The facility has a two day supply of perishable food items and seven day supply of nonperishable food items. All hazardous cleaning chemicals are locked under the sink. There's a closet in the kitchen that's used to store cleaning supplies, and a locked medication cabinet was observed.

Continued on LIC809C Dated 10.21.22

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: ST. IRENEUS CARE VILLA	FACILITY NUMBER: 306005516
	VISIT DATE: 10/21/2022

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The backyard was clean, organized and walkways were free of tripping hazards . Both side side exit gates were self closing and self latching. LPA Haley observed a shaded area with a table and chairs. LPA observed a locked storage shed used to store miscellaneous supplies and gardening tools. There is an additional kitchen in the back yard that remains locked at all times. Three of four burners were operational on the stove in the small backyard kitchen. Behind the storage shed and small kitchen LPA observed a area of clutter with several items that will be disposed of. Bricks, wood, and a headboard are a few of the items observed. Again, LPA Haley advised AD Alipio of the importance of the facility being in clean and in good repair at all times.

The garage was clean and organized. LPA observed an emergency supply of food and water. An emergency supply of PPE was observed. A washer and dryer was observed and a shelf with additional cleaning supplies. Further, there emergency bags for each client were prepared and ready to go.

There were no bodies of water observed. All smoke detectors were tested and are operational. No deficiencies are being cited during todays visit. A technical Advisory was issued for the clutter observed in the backyard and the nonoperating burners on both stoves in the facility.

No deficiencies are being cited during todays visit. An exit interview was conducted and a copy of this report and LIC 9102 was provided to Administrator Alipio.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC809 (FAS) - (06/04)

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